Research

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Patients’ awareness of the surgical risks of smoking Implications for supporting smoking cessation Joan L. Bottorff

PhD RN FCAHS FAAN 

Cherisse L. Seaton

PhD 

Sonia Lamont

MBA

Abstract Objective To describe the smoking patterns of patients receiving elective surgery and their knowledge about the benefits of smoking cessation to inform and strengthen support for patients to quit smoking in order to optimize surgical outcomes. Design  Patients who had elective surgery were screened for smoking status, and eligible patients completed a telephone survey. Setting  Two regional hospitals in northern British Columbia. Participants  Of 1722 patients screened, 373 reported smoking before surgery. Of these, 161 (59.0% women) completed a telephone survey. Main outcome measures Patient smoking cessation, knowledge of the perioperative risks of smoking, use of resources, and health care provider advice and assistance. Results  Participants included 66 men and 95 women (mean [SD] age of 51.9 [14.0] years). In total, 7.5% of these patients quit smoking in the 8 weeks before their surgeries, although an additional 38.8% reduced their smoking. Only about half of the patients surveyed were aware that continuing to smoke increased their surgical risks. Further, only half of the patients surveyed reported being advised to quit before their surgeries by a health care professional. Few were using the provincial resources available to support smoking cessation (eg, QuitNow), and 39.6% were unaware of the provincial program to cover the cost of smoking cessation aids (eg, nicotine gum or patches), yet 62.7% of respondents were thinking about quitting smoking. Conclusion  Many surgical patients in northern British Columbia who smoked were unaware of the perioperative risks of smoking and the cessation support available to them. An opportunity exists for all health care professionals to encourage more patients to quit in order to optimize their surgical outcomes.

EDITOR’S KEY POINTS

 • There is a substantive body of evidence linking smoking before surgery to increased perioperative risks. This survey of surgical patients from northern British Columbia who smoked revealed that many of them were unaware of the perioperative risks of smoking, only half were advised to quit smoking before their surgery, and few used provincial cessation resources.  • Increasing patient knowledge of the surgical risks of smoking and the availability of cessation resources might encourage more patients to quit before surgery and optimize surgical outcomes. This article has been peer reviewed. Can Fam Physician 2015;61:e562-9

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Les patients sont-ils conscients des risques opératoires associés au tabagisme? L’importance d’aider les patients à cesser de fumer Joan L. Bottorff

PhD RN FCAHS FAAN 

Cherisse L. Seaton

PhD 

Sonia Lamont

MBA

Résumé Objectif  Décrire les habitudes de tabagisme de patients en attente d’une chirurgie élective et déterminer ce qu’ils savent des avantages d’arrêter de fumer, les renseigner sur les méthodes favorisant l’arrêt du tabac et ainsi optimiser les résultats des chirurgies. Type d’étude On a évalué les habitudes de tabagisme chez des patients en attente d’une chirurgie élective; on a demandé aux patients admissibles de répondre à une enquête téléphonique. Contexte  Deux hôpitaux régionaux du nord de la Colombie-Britannique. Participants  Sur les 1722 patients qui ont été évalués, 373 ont déclaré qu’ils fumaient avant d’être opérés. Parmi ces derniers, 161 (dont 59,0 % de femmes) ont répondu à l’enquête téléphonique. Principaux paramètres à l’étude L’abandon du tagabisme par les patients, leur connaissance des risques périopératoires associés au tabac, leur utilisation des ressources disponibles, et les conseils et l’assistance fournis par les professionnels de la santé. Résultats  Les participants comprenaient 66 hommes et 95 femmes (âge moyen [DS] : 51,9 [14,0]). Dans l’ensemble, 7,5 % de ces patients ont cessé de fumer au cours des 8 semaines précédant l’opération, et 38,8 % de plus ont réduit leur consommation de tabac. Seulement la moitié environ des participants savaient que le fait de continuer de fumer augmente les risques péri-opératoires. En outre, la moitié seulement a rapporté qu’un professionnel de la santé leur avait conseillé de cesser de fumer avant l’opération. Peu de répondants avaient recours aux mesures provinciales disponibles Points de repère du rédacteur favorisant l’arrêt du tabagisme (p. ex. QuitNow), et 39,6 % d’entre • De nombreuses données indiquent que le fait eux n’étaient pas au courant du programme provincial qui couvre de fumer avant une opération augmente les le coût des mesures favorisant l’arrêt du tabagisme (p. ex. la risques péri-opératoires. Cette enquête chez des gomme ou les timbres à la nicotine), et pourtant 62,7 % des fumeurs du nord de la Colombie-Britannique en répondants envisageaient déjà d’arrêter de fumer. attente d’une chirurgie a révélé que plusieurs

d’entre eux n’étaient pas conscients des risques péri-opératoires qu’ils encouraient en fumant; seulement la moitié avait eu le conseil de cesser de fumer avant l’opération et seuls quelques-uns avaient eu recours aux ressources provinciales favorisant l’arrêt du tabac. • En renseignant davantage les patients sur les risques chirurgicaux associés au tabagisme et sur les ressources existantes pour arrêter de fumer, on pourrait aider plus de patients à cesser de fumer avant leur intervention et ainsi optimiser les résultats des chirurgies.

Conclusion  Plusieurs fumeurs du nord de la Colombie-Britannique en attente de chirurgie ne connaissaient pas les risques périopératoires associés au tabac et ignoraient les mesures existantes pour les aider à arrêter. Les professionnels de la santé ont donc là une excellente occasion d’inciter davantage de patients à cesser de fumer pour optimiser leurs résultats chirurgicaux.

Cet article a fait l’objet d’une révision par des pairs. Can Fam Physician 2015;61:e562-9

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Research | Patients’ awareness of the surgical risks of smoking

T

he challenges inherent in meeting the need for surgical services in northern and rural regions of Canada have been addressed through various practice models involving resident specialist surgeons and general practitioner surgeons, as well as family physicians and other health professionals.1 Accordingly, in low-volume centres, ensuring the quality and convenience of care for patients before and after surgery is a responsibility that is shared by a range of health care providers, including family physicians in remote communities served by these centres, where surgical patients might reside. In regions where smoking rates are high, one important way to optimize surgical outcomes is to support smoking cessation. Surgical patients who smoke have greater risk of poor intraoperative and postoperative outcomes, including general morbidity, wound complications (eg, surgical site infections, slower healing, dehiscence, delayed healing), general infections, pulmonary complications (eg, unplanned intubation, reduced pulmonary function, and mucus accumulation with immobilization during and after surgery), neurologic complications, and admission to intensive care units.2-5 It is important, therefore, to ensure that surgical patients who smoke are aware of their increased surgical risks. A recent survey of surgical patient smokers in Australia revealed that less than half were aware of the perioperative risks of smoking.6 Although an upcoming surgery has been described as a “teachable moment” for cessation,7 in Canada efforts to encourage patients to quit before surgery are relatively recent, sporadic, and lacking a systematic approach. Notably, some work has taken place in western Canada, and the most formalized examples are in Ontario.8 Nevertheless, there are unique challenges in providing smoking cessation support to surgical patients in rural and remote communities, where there is often a low volume of surgeries (relative to large urban centres). The integration of tobacco use interventions into routine care in multiple heterogeneous centres competes with other priorities, and ongoing training and support for health care professionals who are geographically dispersed can be difficult. Despite this, the absence of consistent identification and education of this patient population presents an opportunity for improved patient care.9 In Canada, nearly half of all smokers report that they attempted to quit in the past year, and two-thirds were planning to quit within the next 6 months.10 The smoking rate in northern British Columbia (BC) in 2012 was 24%, substantially higher than the provincial average of 11%.10,11 The region also has the highest rate of lung cancer in the province. Consequently, implementing new approaches to support smoking cessation is a priority for strengthening cancer prevention in northern BC. Although patients who smoke benefit from smoking cessation support before surgery,12 up-to-date information

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is lacking from northern and rural regions about smoking cessation rates among surgical patients and the information and support they receive for cessation. This information is needed to guide future efforts to enhance health care services in these regions. The objectives of this study were to survey a sample of northern BC surgical patients who smoked in order to investigate their level of knowledge about the perioperative risks of smoking, the proportion of patients who quit smoking before surgery, whether health care provider advice was received, and patients’ knowledge and use of resources to support smoking cessation.

Methods

Study design This research was approved by the University of British Columbia Behavioural Research Ethics Board and the Northern Health Research Review Committee. This cross-sectional study involved surveying surgical patients recruited from 2 regional hospitals serving northern BC residents. One hospital, a 200-bed facility near the centre of BC, carries out approximately 5700 surgeries annually. The second, a 25-bed facility located in the northwest that performs approximately 1600 surgeries annually, was chosen to represent other northern regional hospitals offering a full range of services. A provincewide effort and a tobacco reduction policy in the health authority were in place to encourage health care providers to advise and assist with cessation.

Sample and procedure To recruit participants, patients (n = 2251) who underwent elective surgery at the 2 hospitals between December 1, 2012, and March 31, 2013, were contacted and screened. Of the 1722 patients contacted, 373 (21.7%) reported smoking at least 1 cigarette in the 6 months before their surgeries. Of these, 279 patients provided consent to have their contact information released and were forwarded a letter about the study before receiving a telephone call inviting them to participate in a telephone survey. Figure 1 outlines participant inclusion and exclusion. Patients who participated in the telephone survey were mailed a $5 gift card.

Measures Items assessing tobacco use were derived from measures used in national surveys and developed by experts in the field. The survey was pilot-tested with a subsample of participants (n = 10). Patients were asked about their smoking before and after their surgery (eg, Did you smoke cigarettes in any amount in the 2 months before your surgery? In the 2 months before your surgery, how many days in total did you not smoke any

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Patients’ awareness of the surgical risks of smoking | Research Figure 1. Identification of participants

Total no. of surgeries (n=2251)

Excluded duplicates (n=100) Remaining (n=2151) Wrong telephone number or number not in service (n=122) Total attempted contacts (n=2029) Excluded (n=74)

Eligible (smokers) (n=373)

Refused (n=45) Not reached (n=188) Non-smoker (n=1349)

Did not consent to be contacted (n=94)

Reason for exclusion • Unable to communicate by telephone (n=31) • Did not speak English (n=23) • Deceased (n=7) • Readmitted to hospital (n=8) • In long-term care (n=2) • Poor health (n=2) • Patient incarcerated (n=1)

Consented to be contacted (n=279)

Excluded (n=12)

Reason for exclusion • Wrong telephone number or number not in service (n=11) • Language difficulty (n=1)

Eligible (n=267) Not reached (n=73) Did not consent to participate (n=33) Partial surveys (n=2) Completed surveys (n=159)

cigarettes [not even a puff]? During the 2-month period before your surgery, did you reduce your smoking?). Also included were questions about advice and support received from health providers (eg, Did your doctor or another health provider advise you to quit smoking at any time in the 2 months before your surgery? When you were in hospital for your surgery, did anyone ask you about your smoking?). Finally, patients were asked

about any smoking cessation resources they used before surgery (eg, QuitNow) and whether they were aware of the BC Ministry of Health program to cover the cost of smoking cessation aids (eg, nicotine gum or patches). Two measures with established reliability and validity were also included to describe the patient sample: the smoking stages of change scale (short form) based on the transtheoretical model of behaviour change 13

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Research | Patients’ awareness of the surgical risks of smoking and the Fagerstrom Test for Nicotine Dependence14 (Cronbach a = .65). Finally, a measure developed by Webb and colleagues was included to assess awareness of smoking-related perioperative complications.6 Using a Likert response scale (very likely = 3; somewhat likely = 2; somewhat unlikely = 1; very unlikely = 0; do not know = 0), patients were asked, “As far as you know, does smoking make any of the following likely?” for each of slower healing of wounds after surgery, increased risk of infection after surgery, increased pain after surgery, increased complications with the anesthesia, and increased risk of future heart or lung problems. Responses to the first 4 items were averaged to create a scale for awareness of smoking-related perioperative complications, with scores ranging from 0 to 3 (Cronbach a = .75). The last item assessed future health problems related to smoking and was scored separately.

Data analysis Categorical variables were summarized using frequencies and percentages, and continuous variables were summarized using means and standard deviations. Data analyses were completed using SPSS, version 21.0.

Value

Mean (SD) age, y

51.9 (14.0)

Female, n (%)

95 (59.0)

Ethnicity, n (%)* • White

122 (76.7)

• First Nations or Metis

32 (20.1)

• Asian

2 (1.3)

• Other

3 (1.9)

Marital status, n (%)* • Single

28 (17.6)

• Married or common-law

93 (58.5)

• Separated or divorced

28 (17.6)

• Widowed

10 (6.3)

Education level, n (%)* • Some high school or less

41 (25.8)

• High school

40 (25.2)

• Trade certification or some college

46 (28.9)

• Community college degree

11 (6.9) 8 (5.0)

• University undergraduate degree

In total 161 patients (66 men, 95 women), ranging in age from 20 to 78 years, participated in the survey. This represents a response rate of 60.3% of eligible participants. Demographic and smoking-related characteristics are displayed in Tables 1 and 2, respectively. In total, 105 (65.6%) patients reported that they quit smoking for at least 24 hours in the 2 months before their surgery. Presurgical quit durations were predominately short (Table 3), yet 12 (7.5%) patients abstained from smoking for the entire 8 weeks before their surgery, and an additional 62 (38.8%) reported that they reduced their smoking. Independent-samples t tests and χ2 analyses revealed that the samples from the 2 hospitals did not differ on any demographic or smoking-related variables. Although most patients correctly identified future heart and lung problems as a smoking-related risk, the mean (SD) score on the awareness of smoking-related perioperative complications scale was low (1.22 [0.83], range 0 to 3). Slightly more than half identified slower healing as being “very likely or somewhat likely”; however, less than half were aware of the association between smoking and postsurgical infection, pain after surgery, or complications with anesthesia (Figure 2). Patients who quit or reduced their smoking before surgery did not have a higher mean (SD) awareness score (1.20 [0.88]) than those who continued to smoke the same amount (1.23 [0.79]; F1,156 = 0.05, P = .83). Canadian Family Physician • Le Médecin de famille canadien

characteristic

• Some university

RESULTS

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Table 1. Demographic characteristics of the patient sample: N = 161; not all participants answered all questions.

• University postgraduate degree

11 (6.9) 2 (1.3)

Employment status, n (%)* • Full-time

74 (46.5)

• Part-time

17 (10.7)

• Not employed

34 (21.4)

• Retired

34 (21.4)

Annual household income, n (%)

†

•